What is schizophrenia?
Schizophrenia is a psychosis. That is, a severe mental disorder in which the person’s emotions, thinking, judgment, and grasp of reality are so disturbed that his or her functioning is seriously impaired.
The symptoms of schizophrenia are often divided into “positive” and “negative.” Positive symptoms are abnormal experiences and perceptions like delusions, hallucinations, illogical and disorganized thinking and inappropriate behavior. Negative symptoms are the absence of normal thoughts, emotions and behavior; such as blunted emotions, loss of drive, poverty of thought, and social withdrawal.
The distinction between schizophrenia and the other common psychotic disorders such as depressive psychosis, bipolar disorder and schizoaffective disorder is not easy to make. Bipolar disorder is an episodic disorder in which psychotic symptoms are associated with severe alterations in mood—at times elated, agitated episodes of mania, at other times depression, with physical and mental slowing, despair, guilt and low self-esteem. Depressive psychosis is similar, but without any episodes of mania.
The course of schizophrenia, though fluctuating, tends to be more continuous than bipolar disorder or depressive psychosis, and the person’s display of emotion is likely to be incongruous or lacking in spontaneity. Markedly illogical thinking is common in schizophrenia. Auditory hallucinations may occur in any of these psychotic disorders, but in schizophrenia they are more likely to be commenting on the person’s actions or to be conversing one with another. Delusions, also, can occur in any psychotic illness; in schizophrenia they may give the individual the sense that he or she is being controlled by outside forces or that his or her thoughts are being broadcast or interfered with.
What is schizoaffective disorder?
Some people display features of both schizophrenia and an affective disorder such as bipolar disorder or major depression with psychotic features. In depression, the person may experience hallucinations or delusions about guilt, disease or death and be slowed down in speech, thinking and movement. In bipolar disorder, there are depressive and manic phases of illness. In the manic phase, the content of the hallucinations and delusions is usually grandiose and the person is likely to be very energetic, talkative, sleepless and overassertive. But if the illness also displays, at times, psychotic symptoms with a neutral content — bizarre beliefs, messages or behavior that do not reflect a depressed or elevated mood — then the diagnosis could be schizoaffective disorder.
Mania and depression are usually episodic and can be interspersed with long periods of complete remission of symptoms. If the illness is continuous, with no remission, then the diagnosis may be schizoaffective disorder.
The treatment for schizoaffective disorder, bipolar disorder and major depression with psychosis is very similar. If both manic episodes and depressive episodes are evident, the medications used are likely to include antipsychotic agents and mood stabilizers. If the illness only presents with depressive features and no manic symptoms at any time, then antidepressants are likely to be used.
What is bipolar disorder?
Bipolar disorder is an episodic and recurrent disorder in which the psychotic symptoms are associated with severe alterations in mood—at times elated, agitated episodes of mania, at other times depression, with physical and mental slowing, despair, guilt feelings and low self-esteem.
Auditory hallucinations may occur in bipolar disorder, just as they can in schizophrenia. In the manic phase of bipolar disorder, the hallucinations may be congratulatory or paranoid but in the depressive phase they are likely to be critical, abusive or guilt-inducing. In schizophrenia, they are more likely to be neutral – commenting on the person’s thoughts and actions or conversing one with another.
Delusions, also, can occur in bipolar disorder or in schizophrenia. In mania, they may be grandiose or ecstatic, leading the person to feel he or she has achieved, or will achieve, magnificent things, or has a special connection to God or the universe. In depression they often focus on death, disease or guilt.
In the manic phase of bipolar disorder the person is likely to be energetic and need little sleep. He or she may be exhilarated or ecstatic, talkative and argumentative, and enthused about his or her plans, many of them unrealistic. The person may be impatient, impulsive, and resist any attempts to dissuade him or her from irrational plans or from dangerous or harmful behavior. He or she may have grandiose or paranoid delusions and experience hallucinations that reinforce the delusions.
When the episode is milder and the person’s judgment is less severely impaired and no hallucinations or delusions are present, the episode is referred to as “hypomania.”
In the depressed phase of the disorder the person is likely to be slowed down, lacking in energy and unwilling to get out of bed or leave the house. Sleep may be excessive or disturbed. The person often wakes feeling unrested. He or she may ruminate about negative events in his or her life, feel helpless and hopeless, have low self-esteem, and think, plan or attempt suicide.
The depressive episode may be free of psychotic symptoms but, when delusions are present, they often focus on death, disease, or guilt about some imagined offence, and hallucinations are likely to be critical or abusive in nature.
Confusion has arisen regarding the diagnosis of bipolar disorder in recent years due to the practice among child psychiatrists in the U.S of diagnosing aggressive and irritable children with volatile emotions as suffering from “bipolar disorder.” The vast majority of these children never go on to develop bipolar disorder, with the features described above, in adulthood. However, the practice has led to an expansion of the rate of diagnosis of bipolar disorder to 40 times the previous prevalence.
The American Psychiatric Association has rectified this error with the publication, in 2013, of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). The revised manual requires emotionally volatile children of this type to be diagnosed as suffering from “disruptive mood dysregulation disorder.” With this change, it again becomes clear that “bipolar disorder” is a distinct entity and follows the description above.
Can depression cause psychosis?
The short answer to this question is, “Yes.” Depression can cause psychotic symptoms, including delusions and hallucinations. These symptoms will most often reflect depressive themes like personal inadequacy, guilt, disease, death, punishment, and worthlessness. For example, a person who is experiencing depression with psychosis may develop false beliefs that he or she is afflicted with a physical illness or hear ridiculing, criticizing voices. In addition to these types of symptoms, people experiencing depression with psychosis might experience other symptoms typical of depression such as agitation, anxiety, hypochondria, insomnia or excessive sleep, poor concentration and lack of energy or motivation.
Psychosis is more common in severe depression, affecting roughly one in four people who are admitted to the hospital for depression. Those who have experienced one episode of psychosis with depression can be at an increased risk of recurrent depressive episodes, bipolar disorder, and suicide. For these reasons, accurate diagnosis is important.
Effective treatment for depression with psychosis involves intensive psychiatric treatment and therapy in a monitored setting. A combination of antidepressant and antipsychotic medication is often used early on in the stabilization of symptoms. Unlike some other disorders that include symptoms of psychosis, like schizophrenia, a person may not need to take an antipsychotic medication long-term to successfully treat the illness. Electroconvulsive therapy (ECT) can be effective in treating this illness but it is usually prescribed only after other means of treatment have proven ineffective.
The good news regarding depression with psychosis is that treatment is commonly very effective. People are frequently able to recover from an acute phase of this illness within a few weeks or months. Continued psychiatric follow-up is necessary, however, and it is common that individuals experiencing this illness will need to work closely with their doctors to find the most effective treatment for their depression with the fewest side effects.
What alternatives are there to mental hospital?
Acute Residential Treatment
Small, open-door, non-coercive, domestic settings providing services that are similar to those in a psychiatric hospital unit have been operating for decades in many places around the world including Boulder, Colorado; Vancouver, British Columbia; and Trieste, Italy. These alternative settings offer a non-institutional, unlocked environment that is genuinely in the community, allowing the resident to stay in touch with relatives, friends, work and social life. They are more flexible than hospital units and are less rule-bound and authoritarian. They offer opportunities for residents to be involved in the operation of the living and treatment environment. Since the cost is lower than hospital care, the pace of treatment in the alternative setting is not so rapid, making it possible to offer a quiet form of genuine asylum.
The recent growth in the use of alternative settings of this type in the US, Britain and elsewhere is a trend that reflects the emergence of the recovery model which emphasizes the importance of patient empowerment and interpersonal support. In line with the recovery movement, alternatives to the hospital offer a treatment approach in which coercion and paternalism are reduced and peer support is encouraged. They offer a treatment atmosphere with more autonomy for residents and staff. Important benefits include their cost-effectiveness, greater emphasis on human interaction rather than medication, and greater user-satisfaction.
Cedar House (now renamed Warner House), a 16-bed hospital alternative that has been in operation for over 30 years in the public mental health system of Boulder County, Colorado, has been able to accommodate at least half of the people in need of acute inpatient care at any point in time, including many patients requiring compulsory treatment.
Balsam House, the residential treatment facility of Colorado Recovery, in Boulder, accepts acutely ill patients who would otherwise need to be in hospital treatment, including many of those requiring involuntary treatment, when necessary.
What do these facilities do if the acutely ill person is suicidal or aggressive or insists on walking away from treatment? The staff, who are there 24 hours a day and have psychiatrists on-call, continuously evaluate the person for features like these and arrange for hospital admission if he or she can’t be managed in the residence. There is no hesitation to do this when necessary but, in fact, it doesn’t happen very often.
Assertive Community Treatment
Assertive community treatment (ACT) teams aim to prevent relapse and readmission to inpatient care for people who have already demonstrated a pattern of frequent hospital admission. ACT teams provide a wide range of services to people with a high risk of relapse: on a daily basis they administer medication; disburse money; search for people who drop out of treatment; accompany clients to doctor appointments, court hearings, social services and the like; evaluate and improve their clients’ living conditions: and help with shopping, house cleaning, finding accommodation, resolving problems with their family, their landlord, employer and others.
There is a lot of research that demonstrates that ACT improves continuity of care, reduces relapse and hospital readmission and the overall cost of treatment, improves the quality of life and housing stability for clients and leads to a reduction in their symptoms of illness.
At Colorado Recovery we have established a model of intensive outpatient care that replicates the features of ACT and is designed to help those clients who are likely to relapse if they receive less intensive services. This individualized level of community treatment ensures that clients have a lifestyle that is as independent, healthy, and productive as possible.
How can I help a loved one who is unwilling to seek treatment?
This is a dilemma faced by many who care for someone with a major mental illness. There are many obstacles that can prompt someone with serious mental illness to refuse psychiatric treatment. Medications often have debilitating side effects; and substance abuse, that often accompanies psychiatric illness, can impede judgment and the development of insight.
Lack of insight into one’s illness is common in schizophrenia, schizoaffective disorder, and bipolar disorder; it affects 50% of people diagnosed with schizophrenia and 40% of those with bipolar disorder. A person who is not fully aware that he or she has an illness is less likely to take medication consistently and is more likely to experience a poor outcome, such as re-hospitalization, incarceration, victimization, and suicide. Someone who lacks insight cannot simply change his or her level of understanding; it takes time and, sometimes, repeated experience of the negative effects of the illness.
Education, collaboration, and compromise can help people engage in treatment. Treatment compliance is often improved when the individual is well informed about his or her diagnosis, treatment options, and the long-term prognosis for the illness. Taking medication can often be simplified by using pill minders or monthly injectable forms. Encouraging your family member to talk with a trusted therapist or psychiatrist can help create a treatment alliance with someone who can guide him or her towards medication choices with reduced side effects and provide education about their medication.
Using a non-judgmental and empathic approach in talking with your family member will help him or her feel supported and encouraged, and may help him or her assess the risks and benefits of not taking medication.
When someone is unwilling to seek treatment it often becomes necessary look around for incentives or to pursue involuntary treatment options. Sometimes subsidized public housing requires adherence to psychiatric treatment. If you are financially supporting your family member you could also use financial incentives to encourage his or her acceptance of treatment. If someone with a mental illness commits a criminal offense, mental health care is often stipulated as a condition of probation.
People who are suffering from mental illness can become so ill that they lose the capacity to care for themselves, use appropriate judgment or are at risk of hurting themselves or others. If these risks are present, a family member or friend can use the help of the medical and legal systems to get the person into treatment, including court-ordered medication. Each state has different laws for initiating involuntary treatment. Contacting your City or County Attorney’s office will help you to understand the process in your area.
If an emergency exists, a health care provider or the police can issue a legal hold for treatment for a brief period of time. This can initiate the process of court-ordered medication. With time on involuntary medication, many patients gain insight into their illness or recognize a benefit from medication and are then willing to take medication voluntarily.
How can I get my family member to take his or her medication?
The issue has been addressed in answering the previous question, “How can I help a loved one who is unwilling to seek treatment?”
But let’s get another viewpoint, spelled out in this blog by Pete Earley, a mental health advocate, journalist and bestselling author of Crazy: A Father’s Search Through America’s Mental Health Madness.
Here’s what Pete has to say:
“Why won’t you just take your medication? I take pills for my cholesterol every night and it’s no big deal?”
“Every psychiatrist we’ve seen has said you have a mental illness. Why won’t you accept it? Why would the doctors tell you that you’re sick, if it weren’t true?”
Let’s look at when you were doing well and when you got into trouble. What was the difference? Medication. It was the difference. When you were on your meds, you were fine. And when you weren’t, you got into trouble. Can’t you see that?”
These quotes may sound familiar to you if you are a parent and have a son or daughter with a severe mental illness. I’ve said every one of them to my son, Mike.
It often is frustrating for us – parents — to understand why our children will not take anti-psychotic medication or take it only until they get better and then stop. The remedy seems so clear-cut to us, so simple – and watching them experience the mania, depression, and delusions that happen when they become psychotic is heartbreaking and horrific.
Early on, I tried every trick out there to get Mike to take his pills. Those of you who have read my book know that during one of his first breakdowns, I crushed his pills and mixed them into his breakfast cereal only to be caught by him. I snuck into his room and counted his pills too one day and when I discovered that he had stopped taking them. I followed the advice of a therapist who had told me that I needed to practice “tough love.” I told Mike that if he didn’t take his medication, he had to move out of my house. He did – that very same day.
Another time, I offered to pay him to take his medication — a $1 per pill.
Xavier Amador, author of the book, “I’m Not Sick, I Don’t Need Help” finally convinced me to back off. “I can promise you, Pete,” he said, “Your son knows exactly how you feel about medication. You don’t need to ever mention it to him again.” And since that day, I haven’t. Not a word.
It was my friend, Xavier Amador, author of the book, “I’m Not Sick, I Don’t Need Help” who finally convinced me to back off. “I can promise you, Pete,” he said, “your son knows exactly how you feel about medication. You don’t need to ever mention it to him again.”
And since that day, I haven’t. Not a word.
So why do persons with mental illnesses refuse to take their medication or stop taking them as soon as they become stable?
I am asked that question more than any other after I give a speech.
Let’s skip the obvious reasons –that some anti-psychotic medications can dull a person, make them feel physically lousy, kill their sex drive, cause them to gain weight or send them to bed exhausted even though they are already sleeping for 16 hours a day. Let’s ignore the fact that no one really knows the long term health impact that medication can cause on a person’s body.
Instead, let’s dig deeper.
One day, I asked Mike to explain to me in writing why he had struggled so much when it came to taking his medication.
Denial was a strong factor in my understanding and even when evidence of my own madness would be presented, my mind would find a way to weave out of the circumstance and an obtuse reasoning would somehow form that would keep my own pride intact. Always two steps ahead of the truth, my brain would tapdance its way into a room where I was not at fault, where it was everybody else versus me, where I was some sort of prophet or special medium who was undergoing visions, not hallucinations, and I was important, not a victim.
It is very hard to understand that one’s own credibility is broken. There is a lot of personal shame one undergoes when they realize that they are no longer in line with society’s understanding of sane. It makes one doubt one’s own instincts and second guess the movements and decisions that one makes. Suddenly, the veil of confidence and ability has been lifted and one is a wreck, struggling to piece together the remnants of what are left of one’s self-image.
I learn a lot from my son. One lesson he has taught me is that taking anti-psychotic medication is much more complicated than being told by your doctor that you have high cholesterol.
Can people with serious mental illness have a normal life?
Yes! Most people with mental illnesses can recover and resume their usual activities. Many find employment or other meaningful productive activity, or return to their educational goals, and continue to have rewarding relationships and carry on successfully with their lives. Their timeline for reaching their goals may, however, be waylaid for a period of time due to an exacerbation of symptoms and the stabilization process.
Over the course of years, about 20 to 25 percent of people with schizophrenia, for example, recover completely from the illness – all their psychotic symptoms disappear and they return to their previous level of functioning. Another 20 percent continue to have some symptoms, but they are able to lead satisfying and productive lives. They may need hospitalization initially, followed by residential and intensive outpatient services, as well as subsequent aftercare until they reach a level of stability that allows them to resume or re-create their lives. Some achieve stability eventually without continued use of medication.
Psychosocial rehabilitation may be required to reintegrate the person into the community and to develop new relationships. He or she may also need to heal conflicts in established relationships and relearn interpersonal skills.
Vocational rehabilitation may be helpful in developing resumes, pursuing educational interests, finding volunteer or paid work, and in developing the necessary skills to succeed and flourish in their chosen career.
Ongoing therapy and medication adjustments may be necessary to maintain recovery. The length of time to reach stability depends on the severity of illness, individual losses and challenges, and internal and material resources. Many experience multiple hospitalizations and periods of treatment prior to developing the motivation to engage in treatment. Even after multiple episodes of treatment or hospitalizations, many find recovery!
Where can I find treatment for both mental illness and alcohol/drug abuse?
The relationship between substance abuse and mental illness is complicated and a variety of factors are taken into consideration when addressing these problems in treatment. It can be common for an individual to use drugs and alcohol as a form of self-medication when they are experiencing psychiatric symptoms, using substances to control or dampen their distressing moods and thoughts. This often leads to short-term relief while it exacerbates the long term course of illness. Substance use can result in heightened spikes in psychiatric symptoms during intoxication and withdrawal. Drug use is a common trigger or precursor to the onset of ongoing psychiatric symptoms.
Treatment for co-occurring substance abuse problems and mental illness requires a different approach than either issue requires on its own. Finding appropriate treatment for co-occurring disorders can be daunting. With patience and commitment, recovery is possible. It is important to find a treatment provider that works with both mental health and substance abuse problems. Many treatment facilities focus on one area of mental health (e.g. depression), so it is important to find out if a program specializes in the type of mental illness that your loved one is experiencing.
Co-occurring disorders require an individual to have a safe space to talk about the role that substance use plays in their life. It is essential that such treatment include education geared toward understanding the impact of substance use on one’s health. Effective co-occurring disorders treatment involves encouragement towards developing coping strategies and self-regulation techniques. It should also include integrated care to address the myriad of life skills and case management needs that invariably arise. Social and vocational programming, peer-support, and assistance with accessing social and health services should also be considered in comprehensive treatment planning for co-occurring disorders.
